What are the steroid management options for Chronic Obstructive Pulmonary Disease (COPD) after an exacerbation?

From the Guidelines

Steroid management after a COPD exacerbation should involve a short course of oral corticosteroids, such as prednisone 40mg daily for 5 days, to reduce inflammation and improve lung function, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.

Key Considerations

• The use of systemic corticosteroids should be limited to the first 30 days following the initial acute exacerbation of COPD, as recommended by the American College of Chest Physicians and Canadian Thoracic Society guideline 1.
• Inhaled corticosteroids (ICS) may be considered for long-term management, particularly for patients with frequent exacerbations or elevated eosinophil counts (≥300 cells/μL), as part of combination therapy with long-acting bronchodilators.
• Common ICS combinations include fluticasone/vilanterol (Breo Ellipta), budesonide/formoterol (Symbicort), or fluticasone/salmeterol (Advair), typically used once or twice daily depending on the formulation.

Monitoring and Follow-up

• Patients should be monitored for potential side effects of long-term ICS use, including oral thrush, hoarse voice, and increased risk of pneumonia.
• Patients should be instructed to rinse their mouth after using ICS to reduce the risk of thrush.
• Regular follow-up appointments are essential to assess treatment response and adjust therapy as needed based on symptom control and exacerbation frequency.

Additional Recommendations

• Noninvasive mechanical ventilation should be considered for patients with acute or acute-on-chronic respiratory failure, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.
• Pulmonary rehabilitation should be initiated within 3 weeks after hospital discharge for patients who are hospitalized with a COPD exacerbation, as recommended by the European Respiratory Society/American Thoracic Society guideline 1.

From the FDA Drug Label

The 2 exacerbation trials with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg were identical trials designed to evaluate the effect of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and salmeterol 50 mcg, each given twice daily, on exacerbations of COPD over a 12-month period Subjects treated with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg also had a significantly lower annual rate of exacerbations requiring treatment with oral corticosteroids compared with subjects treated with salmeterol

The steroid management options for Chronic Obstructive Pulmonary Disease (COPD) after an exacerbation include:

• Fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg, which has been shown to reduce the annual rate of moderate/severe COPD exacerbations and exacerbations requiring treatment with oral corticosteroids compared to salmeterol alone 2
• Fluticasone propionate and salmeterol inhalation powder 500 mcg/50 mcg, which has been shown to reduce the rate of moderate and severe exacerbations compared to placebo, but not when compared to its components 2 Key points to consider:
• The use of oral corticosteroids may be reduced with the use of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg 2
• The management of COPD exacerbations should be individualized and based on the severity of the exacerbation and the patient's response to treatment 2

From the Research

Steroid Management Options for COPD After Exacerbation

The management of Chronic Obstructive Pulmonary Disease (COPD) after an exacerbation often involves the use of corticosteroids to reduce inflammation and improve symptoms. The duration and dosage of corticosteroid treatment can vary, and several studies have investigated the optimal approach.

• Duration of Corticosteroid Treatment: A study published in 2018 3 compared the efficacy of short-duration (seven or fewer days) and conventional longer-duration (longer than seven days) systemic corticosteroid treatment for adults with acute exacerbations of COPD. The results suggested that shorter courses of systemic corticosteroids (of around five days) may not lead to worse outcomes than longer courses.
• Reduction of Corticosteroid Use: A study protocol published in 2019 4 aimed to investigate whether a 3-day treatment with orally administered corticosteroids is non-inferior to a 5-day treatment in acute exacerbations of COPD in a primary-care setting. This study highlights the need to reduce cumulative corticosteroid dose in COPD patients.
• Improving Adherence to Guidelines: A study published in 2014 5 implemented an evidence-based order set to standardize treatment of patients hospitalized with acute exacerbations of COPD. The results showed that the median amount of corticosteroid used in the first 48 hours was significantly reduced, and the total dose of corticosteroid administered during the entire hospitalization was also reduced.
• Combination Therapy: A study published in 2007 6 investigated the effect of combining tiotropium with salmeterol or fluticasone-salmeterol in patients with moderate to severe COPD. The results suggested that adding fluticasone-salmeterol to tiotropium therapy improved lung function, quality of life, and hospitalization rates.
• Eosinophil-Guided Corticosteroid Therapy: A study published in 2019 7 investigated the use of an algorithm based on blood eosinophil counts to guide corticosteroid therapy in patients admitted to hospital with acute exacerbations of COPD. The results showed that eosinophil-guided therapy was non-inferior to standard care and reduced the duration of systemic corticosteroid exposure.

Key Findings

• Shorter courses of systemic corticosteroids (of around five days) may be sufficient for treating acute exacerbations of COPD.
• Reducing the cumulative corticosteroid dose in COPD patients is essential to minimize adverse effects.
• Implementing evidence-based order sets can improve adherence to guidelines and reduce corticosteroid use.
• Combination therapy with tiotropium and fluticasone-salmeterol may improve lung function, quality of life, and hospitalization rates in patients with moderate to severe COPD.
• Eosinophil-guided corticosteroid therapy may be a promising approach to reduce systemic corticosteroid exposure in patients with acute exacerbations of COPD.